Are you ready to schedule an exam? Do you need new contacts? Do you have questions for the doctor?

We would love to meet with you! Please fill out the information to the right and one of our friendly staff members will be in touch with you soon!



We have offices located in Bexley or Lancaster for your convenience!

Appointment Request Form
Patient Name *
Patient Name
Patient DOB *
Patient DOB
Desired Location
Desired Appointment Date
Desired Appointment Date
Are you interested in a Contact Lens Examination? *
Please fill in your medical insurance provider.
Please fill in the member ID number listed on your medical insurance identification card.
Please fill in your vision insurance provider.
Please fill in the member ID number associated with your vision insurance. If you don't have one, skip this section.
Are you the primary member listed on the insurance policy? *
If you answered no to the previous question, please fill in the following:
Name of Primary
Name of Primary
DOB of Primary
DOB of Primary